Thoracic paravertebral block for implantable cardioverter-defibrillator and laser lead extraction

Anesthetic Choice for Cardiovascular Implantable Electronic Device Placement and Lead Removal: A National Anesthesia Clinical Outcomes Registry Analysis

OBJECTIVE

The authors evaluated the anesthetic approach for cardiovascular implantable electronic device (CIED) placement and transvenous lead removal, hypothesizing that monitored anesthesia care is used more frequently than general anesthesia.

DESIGN

A retrospective study.

SETTING

National Anesthesia Clinical Outcomes Registry data.

PARTICIPANTS

Adult patients who underwent CIED (permanent cardiac pacemaker or implantable cardioverter-defibrillator [ICD]) placement or transvenous lead removal between 2010 and 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Covariates were selected a priori within multivariate models to assess predictors of anesthetic type. A total of 87,530 patients underwent pacemaker placement, 76,140 had ICD placement, 2,568 had pacemaker transvenous lead removal, and 4,861 had ICD transvenous lead extraction; 51.2%, 45.64%, 16.82%, and 45.64% received monitored anesthesia care, respectively. A 2%, 1% (both p < 0.0001), and 2% (p = 0.0003) increase in monitored anesthesia care occurred for each 1-year increase in age for pacemaker placement, ICD placement, and pacemaker transvenous lead removal, respectively. American Society of Anesthesiologists (ASA) physical status ≤III for pacemaker placement, ASA ≥IV for ICD placement, and ASA ≤III for pacemaker transvenous lead removal were 7% (p = 0.0013), 5% (p = 0.0144), and 27% (p = 0.0247) more likely to receive monitored anesthesia care, respectively. Patients treated in the Northeast were more likely to receive monitored anesthesia care than in the West for all groups analyzed (p < 0.0024). Male patients were 24% less likely to receive monitored anesthesia care for pacemaker transvenous lead removal (p = 0.0378). For every additional 10 pacemaker or ICD lead removals performed in a year, a 2% decrease in monitored anesthesia care was evident (p = 0.0271, p < 0.0001, respectively).

CONCLUSIONS

General anesthesia still has a strong presence in the anesthetic management of both CIED placement and transvenous lead removal. Anesthetic choice, however, varies with patient demographics, hospital characteristics, and geographic region.

Comparison of pectoral Nerve (PECS1) block with combined PECS1 and transversus thoracis muscle (TTM) block in patients undergoing cardiac implantable electronic device insertion - A pilot study

Background

Pectoral nerve (PECS1) block has been used for patients undergoing cardiac implantable electronic device (CIED) insertions, however, PECS1 block alone may lead to inadequate analgesia during tunneling and pocket creation because of the highly innervated chest wall. Transversus thoracis muscle plane (TTM) block targeting the anterior branches of T2-T6 intercostal nerves can be effectively used in combination with PECS1 for patients undergoing CIED insertion. The present study hypothesized that combined PECS1 and TTM blocks would provide effective analgesia for patients undergoing CIED insertion compared to PECS1 block alone.

Materials and Methods

Thirty adult patients between the age group of 18-85 years undergoing CIED insertion were enrolled in the study. A prospective, randomized, comparative, pilot study was conducted. A total of 30 patients were enrolled, who were randomized to either Group P: PECS1 block (n = 15) or Group PT: PECS1 and TTM blocks (n = 15). The intraoperative requirement of midazolam and local anesthetic and level of sedation by Ramsay sedation score were noted. The pain was assessed by visual analog scale (VAS) at rest and during a cough or deep breathing at 0 h, 3 h, 6 h, 12 h, and 24 h after the procedure.

Results

VAS scores at rest were significantly lower in group PT at 0, 3, 6, and 12 h postprocedure, and during cough at 0, 6, and 12 h after the procedure (P < 0.05). At 24 h, VAS scores were comparable between both groups. Intraoperative midazolam consumption was higher in group P compared to group PT (P= 0.002). Fourteen patients in group P received local anesthetic supplementation in comparison to only one patient in group PT (P = 0.0001). Thirteen patients in group P received the first rescue analgesia in comparison to three patients in group PT (P = 0.0003).

Conclusion

Combined PECS1 and TTM blocks provide superior analgesia, reduced net consumption of local anesthetic, sedative agents, and rescue analgesics compared to PECS1 block alone in patients undergoing CIED insertion.

Comparison of pectoral Nerve (PECS1) block with combined PECS1 and transversus thoracis muscle (TTM) block in patients undergoing cardiac implantable electronic device insertion - A pilot study

Background

Pectoral nerve (PECS1) block has been used for patients undergoing cardiac implantable electronic device (CIED) insertions, however, PECS1 block alone may lead to inadequate analgesia during tunneling and pocket creation because of the highly innervated chest wall. Transversus thoracis muscle plane (TTM) block targeting the anterior branches of T2-T6 intercostal nerves can be effectively used in combination with PECS1 for patients undergoing CIED insertion. The present study hypothesized that combined PECS1 and TTM blocks would provide effective analgesia for patients undergoing CIED insertion compared to PECS1 block alone.

Materials and Methods

Thirty adult patients between the age group of 18-85 years undergoing CIED insertion were enrolled in the study. A prospective, randomized, comparative, pilot study was conducted. A total of 30 patients were enrolled, who were randomized to either Group P: PECS1 block (n = 15) or Group PT: PECS1 and TTM blocks (n = 15). The intraoperative requirement of midazolam and local anesthetic and level of sedation by Ramsay sedation score were noted. The pain was assessed by visual analog scale (VAS) at rest and during a cough or deep breathing at 0 h, 3 h, 6 h, 12 h, and 24 h after the procedure.

Results

VAS scores at rest were significantly lower in group PT at 0, 3, 6, and 12 h postprocedure, and during cough at 0, 6, and 12 h after the procedure (P < 0.05). At 24 h, VAS scores were comparable between both groups. Intraoperative midazolam consumption was higher in group P compared to group PT (P= 0.002). Fourteen patients in group P received local anesthetic supplementation in comparison to only one patient in group PT (P = 0.0001). Thirteen patients in group P received the first rescue analgesia in comparison to three patients in group PT (P = 0.0003).

Conclusion

Combined PECS1 and TTM blocks provide superior analgesia, reduced net consumption of local anesthetic, sedative agents, and rescue analgesics compared to PECS1 block alone in patients undergoing CIED insertion.

Anaesthesiological support in a cardiac electrophysiology laboratory: a single-centre prospective observational study

BACKGROUND

Implantation of cardiovascular implantable electronic devices (CIEDs) has greatly increased during the last decade and anaesthetic management of these patients remains an open question.

OBJECTIVE

This study describes anaesthetic management and risk factors associated with complications occurring during these procedures.

DESIGN

A single-centre prospective observational study.

SETTING

Grenoble University Hospital, France, from May 2010 to October 2010.

PATIENTS

All patients admitted to the cardiac electrophysiology laboratory were included.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Clinical data, anaesthetic and medical characteristics as well as complications (respiratory or cardiovascular) and treatment were recorded by the anaesthetic nurse at the end of each procedure.

RESULTS

Two hundred and sixty-nine patients were included, 229 (85%) with an American Society of Anaesthesiologists (ASA) status of 3 or 4, 103 (38%) with a New York Heart Association (NYHA) functional class of 3 or 4 and 136 (51%) with a left ventricular ejection fraction of less than 40%. Two hundred and forty-seven (92%) of the patients underwent deep sedation and 12 (8%) general anaesthesia. Seventy-eight (29%) patients had at least one complication, among whom 21 (27%) had at least one considered as severe. Fifty (19%) of the patients had a respiratory complication and 46 (17%) a cardiovascular complication; the latter was more frequently severe (41 vs. 12%; P=0.001). Lead extraction [odds ratio (OR) 13.7, 95% confidence interval (CI) 3.5 to 53.3; P<0.001], NYHA status of 4 (OR 11.8, 95% CI 1.8 to 74.8; P<0.001), implantable cardioverter-defibrillator (ICD) testing by T-wave shock (OR 3.9, 95% CI 1.53 to 10.2; P=0.005) and length of procedure (OR 1.01, 95% CI 1.004 to 1.031; P=0.013) were identified as independent risk factors for cardiovascular complications.

CONCLUSION

Patients requiring cardiovascular implantable electronic device (CIED) implantation were fragile with a high complication rate and a high rate of severe complications even with anaesthesiological support. These complications, as well as the need for deep sedation or general anaesthesia, clearly justify the involvement of a qualified anaesthesiologist.

Paravertebral blocks

Paravertebral blocks have been demonstrated to represent an interesting alternative to epidural, especially for the management of perioperative and trauma pain. Initially performed mostly as single-shot blocks for breast surgery, thoracotomy, and hernia repairs in adults and children, presently these blocks are also used for placement of a paravertebral catheter, either unilateral or bilateral. Although complications associated with the performance of these blocks are infrequent, the use of ultrasound-guided approaches, which allow performing the block under direct vision, is becoming the standard in most groups performing these blocks routinely.